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Hypoxic Respiratory Failure After Transarterial Embolization of Hepatocellular Carcinoma FREE TO VIEW

Shikha Gupta*, MD; Aliya Noor, MD; Homer Twigg, MD
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Indiana University School of Medicine, Indianapolis, IN

Chest. 2012;142(4_MeetingAbstracts):1031A. doi:10.1378/chest.1370704
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SESSION TYPE: Miscellaneous Cases II

PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM

INTRODUCTION: Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. Nonchemotherapeutic (bland) transarterial embolization (TAE) is one of the treatment options for unresectable HCC. We describe a case of hypoxemia after TAE likely due to embolization of microspheres to pulmonary circulation.

CASE PRESENTATION: A 76 year old white male presented for bland TAE of HCC, measuring 7.7 x 6.9 cms. He underwent a planning arteriogram and technetium labeled albumin scan revealed 34% shunting to lungs. During the procedure, he had transient decrease in oxygen saturation, requiring 2 L oxygen via nasal cannula for few hours. After a month, he underwent TAE of hepatic arteries with 40, 100 and 400μm microspheres. The procedure was terminated early as he developed chest pain and hypoxia requiring 4 L oxygen. Over the next few hours, he became progressively more hypoxic and was switched to high flow vapotherm with 100% FiO2. His physical examination was unremarkable except for mild right upper quadrant tenderness. Lung exam revealed no wheezing or rales. Computed tomography of the chest showed stable emphysema and bronchiectatic changes and ruled out pulmonary embolism. Echocardiogram was significant for pulmonary hypertension, with estimated right ventricular systolic pressure of 40 mm Hg. Over the next 10 days, patient was provided with supportive care and oxygen was slowly weaned down. He was discharged home with 3 L of oxygen.

DISCUSSION: HCC is a hypervascular tumor with angiographic findings of arteriovenous shunting, characteristically between hepatic artery and portal vein. Normally there is insignificant shunting with the hepatic venous system. Thus shunting of microspheres to the lungs is an uncommon occurrence. Despite this, there have been case reports of fatal pulmonary complications following embolization of HCC. Autopsies in those patients revealed microspheres in small pulmonary vessels. In most cases, the tumor can act as filter and traps the particles. We believe that the presence of 34% shunt to lungs in our patient predisposed him to microembolization. While we could not prove the diagnosis, the presence of pulmonary hypertension on echocardiogram and unexplained new severe hypoxemia temporally related to the embolization, supports the hypothesis that there were embolization of microspheres into small pulmonary vessels.

CONCLUSIONS: Hypoxemia can occur due to microembolization of particles during TAE of HCC. The presence of high shunt fraction to lungs should lead to consideration of alternate modes of treatment for HCC.

1) Fatal pulmonary complications after arterial embolization with 40-120-μm trisacryl gelatin microspheres. J Vasc Interv Radiol. 2004 Feb;15(2):197-200

2) Bland embolization in patients with unresectable hepatocellular carcinoma using precise, tightly size-calibrated, anti-inflammatory microparticles: first clinical experience and one-year follow-up. Cardiovasc Intervent Radiol. 2010 Jun;33(3):552-9

DISCLOSURE: The following authors have nothing to disclose: Shikha Gupta, Aliya Noor, Homer Twigg

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Indiana University School of Medicine, Indianapolis, IN




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